Laparoscopic Gastric Bypass with Fundectomy and Gastric Remnant Exploration (LRYGBfse): Results at 5-Year Follow-up

  • Giovanni Lesti
  • Alberto Aiolfi
  • Enrico Mozzi
  • Fabrizio Altorio
  • Ezio Lattuada
  • Francesco Lesti
  • Gianluca Bonitta
  • Marco Antonio Zappa
Original Contributions
First Online:
  • 26 Downloads

Abstract

Background

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold standard treatment for morbid obesity. After LRYGB, the endoscopic access to the gastric remnant and pancreaticobiliary system is challenging. The laparoscopic gastric bypass with fundectomy and exploration of the gastric remnant (LRYGBfse) was introduced in an attempt to overcome this limitation. The purpose of this study was to analyze the medium-term outcomes and safety of LRYGBfse.

Methods

Observational prospective single-arm multicenter cohort study. Patients with BMI > 35 kg/m2 were included. Previous open abdominal surgery was an exclusion criterion. Postoperative 1, 2, 3, and 5-year weight loss, BMI decrease, and percentage of excess weight loss (%EWL) were recorded. Wilcoxon signed rank sum test was used for paired data.

Results

Among 653 enrolled patients, 229 completed the 5-year follow-up. Preoperative median body weight (kg) and BMI (kg/m2) were 133.4 kg (interquartile range (IQR) = 12.0) and 48.2 kg/m2 (IQR = 10.1), respectively. Median 5-year body weight, BMI, and %EWL were 83.7 (IQR = 17.3), 31.2 (IQR = 7.7), and 74.8 (IQR = 23.4), respectively, all significantly improved compared to baseline (p = 0.002, p = 0.001, and p = 0.012, respectively). Comorbid improvement or resolution was observed in 88% of the patients. No major intraoperative complications were reported. Postoperative overall morbidity and mortality rates were 1 and 0%, respectively. Banding removal was necessary in one patient 62 months after the index operation.

Conclusions

The LRYGBfse seems safe and effective with durable results at 5-year follow-up. Endoscopic exploration of the gastric remnant is an additional valuable tool.

Keywords

Bariatric surgery Gastric bypass Gastric fundectomy Ghrelin Outcomes 
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Notes

Acknowledgements

The authors thank Maria Tosetti for her help with graphics and figures.

Author Contribution

G.L., A.A, F.L., and M.Z. did the literature search.

G.L., A.A., and M.Z. formed the study design.

Data collection was done by G.L., A.A., E.M., F.A., E.L., and M.Z.

G.L., A.A., and G.B. analyzed the data.

G.L., A.A., and M.Z. interpreted the data.

Compliance with Ethical Standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflict of Interest

The authors declare that they have no conflict of interest.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Angrisani L, Santonicola A, Iovino P, et al. Bariatric surgery worldwide 2013. Obes Surg. 2015 Oct;25(10):1822–32.CrossRefPubMedGoogle Scholar
  2. 2.
    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724–37.CrossRefPubMedGoogle Scholar
  3. 3.
    Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23:427–36.CrossRefPubMedGoogle Scholar
  4. 4.
    Grimes KL, Maciel VH, Mata W, et al. Complications of laparoscopic transgastric ERCP in patients with Roux-en-Y gastric bypass. Surg Endosc. 2015 Jul;29(7):1753–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Frederiksen NA, Tveskov L, Helgstrand F, et al. Treatment of common bile duct stones in gastric bypass patients with laparoscopic transgastric endoscopic retrograde cholangiopancreatography. Obes Surg. 2017 Jun;27(6):1409–13.CrossRefPubMedGoogle Scholar
  6. 6.
    Papasavas PK, Yeaney WW, Caushaj PF, et al. Perforation in the bypassed stomach following laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2003 Oct;13(5):797–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Gypen BJ, Hubens GJ, Hartman V, et al. Perforated duodenal ulcer after laparoscopic gastric bypass. Obes Surg. 2008 Dec;18(12):1644–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Harper JL, Beech D, Tichansky DS, et al. Cancer in the bypassed stomach presenting early after gastric bypass. Obes Surg. 2007 Sep;17(9):1268–71.CrossRefPubMedGoogle Scholar
  9. 9.
    Orlando G, Pilone V, Vitiello A, et al. Gastric cancer following bariatric surgery: a review. Surg Laparosc Endosc Percutan Tech. 2014 Oct;24(5):400–5.CrossRefPubMedGoogle Scholar
  10. 10.
    Mishra T, Lakshmi KK, Peddi KK. Prevalence of cholelithiasis and choledocholithiasis in morbidly obese south Indian patients and the further development of biliary calculus disease after sleeve gastrectomy, gastric bypass and mini gastric bypass. Obes Surg. 2016;26:2411–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Navaratne L, Baltar J, Bustamante M, et al. Treatment of common bile duct stones in gastric bypass patients with laparoscopic transgastric endoscopic retrograde cholangiopancreatography. Obes Surg. 2017 Oct;27(10):2675–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Zappa MA, Aiolfi A, Musolino C, et al. Vertical gastric bypass with fundectomy: feasibility and 2-year follow-up in a series of morbidly obese patients. Obes Surg. 2017 Aug;27(8):2145–50.CrossRefPubMedGoogle Scholar
  13. 13.
    Simonoff JS. Analyzing categorical data. New York, NY: Springer; 2003.CrossRefGoogle Scholar
  14. 14.
    R Core Team. R: a language and environment for statistical computing. R Foundation for Statistical Computing [cited 2016 Mar 14]. Available from: www.r-project.org.
  15. 15.
    Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg. 1994 Nov;4(4):353–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Lehman Center Weight Loss Surgery Expert Panel. Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert Panel on Weight Loss Surgery: executive report. Obes Res. 2005 Feb;13(2):205–26.CrossRefGoogle Scholar
  17. 17.
    Kasama K, Tagaya N, Kanehira E, et al. Laparoscopic sleeve gastrectomy with duodenojejunal bypass: technique and preliminary results. Obes Surg. 2009 Oct;19(10):1341–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Naitoh T, Kasama K, Seki Y, et al. Efficacy of sleeve gastrectomy with duodenal-jejunal bypass for the treatment of obese severe diabetes patients in Japan: a retrospective multicenter study. Obes Surg. 2017 Aug 9;  https://doi.org/10.1007/s11695-017-2874-4. [Epub ahead of print].
  19. 19.
    Schreiner MA, Chang L, Gluck M, et al. Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP in bariatric post-Roux-en-Y gastric bypass patients. Gastrointest Endosc. 2012 Apr;75(4):748–56.CrossRefPubMedGoogle Scholar
  20. 20.
    Abu Dayyeh B. Single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy: getting there. Gastrointest Endosc. 2015;82(1):20–3.CrossRefPubMedGoogle Scholar
  21. 21.
    Shah RJ, Smolkin M, Yen R, et al. A multicenter, U.S. experience of single-balloon, double balloon, and rotational overtube-assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video). Gastrointest Endosc. 2013;77:593–600.CrossRefPubMedGoogle Scholar
  22. 22.
    Saleem A, Baron TH, Gostout CJ, et al. Endoscopic retrograde cholangiopancreatography using a single-balloon enteroscope in patients with altered Roux-en-Y anatomy. Endoscopy. 2010;42:656–60.CrossRefPubMedGoogle Scholar
  23. 23.
    Abbas AM, Strong AT, Diehl DL, et al. Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass. Gastrointest Endosc. 2017 Nov 9. pii: S0016–5107(17)32443–4.Google Scholar
  24. 24.
    Wanjura V, Szabo E, Österberg J, et al. Morbidity of cholecystectomy and gastric bypass in a national database. Br J Surg. 2018 Jan;105(1):121–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Bastouly M, Arasaki CH, Ferreira JB, et al. Early changes in postprandial gallbladder emptying in morbidly obese patients undergoing Roux-en-Y gastric bypass: correlation with the occurrence of biliary sludge and gallstones. Obes Surg. 2009;19:22–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Shiffman ML, Sugerman HJ, Kellum JM, et al. Gallstone formation after rapid weight loss: a prospective study in patients undergoing gastric bypass surgery for treatment of morbid obesity. Am J Gastroenterol. 1991 Aug;86(8):1000–5.PubMedGoogle Scholar
  27. 27.
    Ribeiro-Parenti L, De Courville G, Daikha A, et al. Classification, surgical management and outcomes of patients with gastrogastric fistula after Roux-En-Y gastric bypass. Surg Obes Relat Dis. 2017 Feb;13(2):243–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Carrodeguas L, Szomstein S, Soto F, et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis. 2005 Sep-Oct;1(5):467–74.CrossRefPubMedGoogle Scholar
  29. 29.
    Le Roux CW, Aylwin SJB, Batterham RL, et al. Gut hormone profiles following bariatric surgery for an anorectic state, facilitate weight loss and improve metabolic parameters. Ann Surg. 2006;243:108–14.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Christou NV, Look D, Maclean LD. Pre-and post-prandial ghrelin levels do not related with satiety or failure to achieve a successful outcome after Roux-en-Y gastric bypass. Obes Surg. 2005;15:1017–23.CrossRefPubMedGoogle Scholar
  31. 31.
    Korner J, Bessler M, Cirilo LJ, et al. Effects of gastric Roux-en-Y bypass surgery on fasting and postprandial concentrations of ghrelin, peptideYY, and insulin. J Clin Endocrinol Metab. 2005;90:359–65.CrossRefPubMedGoogle Scholar
  32. 32.
    Geloneze B, Tambascia MA, Pilla VF, et al. Ghrelin: a gut-brain hormone: effect of gastric bypass surgery. Obes Surg. 2003 Feb;13(1):17–22.CrossRefPubMedGoogle Scholar
  33. 33.
    Chronaiou A, Tsoli M, Kehagias I, et al. Lower ghrelin levels and exaggerated postprandial peptide-YY, glucagon-like peptide-1, and insulin responses, after gastric fundus resection, in patients undergoing Roux-en-Y gastric bypass: a randomized clinical trial. Obes Surg. 2012 Nov;22(11):1761–70.CrossRefPubMedGoogle Scholar
  34. 34.
    Langer FB, Prager G, Poglitsch M, et al. Weight loss and weight regain-5-year follow-up for circular- vs. linear-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2013 Jun;23(6):776–81.CrossRefPubMedGoogle Scholar
  35. 35.
    Giordano S, Salminen P, Biancari F, et al. Linear stapler technique may be safer than circular in gastrojejunal anastomosis for laparoscopic Roux-en-Y gastric bypass: a meta-analysis of comparative studies. Obes Surg. 2011 Dec;21(12):1958–64.CrossRefPubMedGoogle Scholar
  36. 36.
    Akkary E, Sidani S, Boonsiri J, et al. The paradox of the pouch: prompt emptying predicts improved weight loss after laparoscopic Roux-Y gastric bypass. Surg Endosc. 2009 Apr;23(4):790–4.CrossRefPubMedGoogle Scholar
  37. 37.
    Rubino F, Schauer PR, Kaplan LM, et al. Metabolic surgery to treat type 2 diabetes: clinical outcomes and mechanisms of action. Annu Rev Med. 2010;61:393–411.CrossRefPubMedGoogle Scholar
  38. 38.
    Cariani S, Palandri P, Della Valle E, et al. Italian multicenter experience of Roux-en-Y gastric bypass on vertical banded gastroplasty: four-year results of effective and safe innovative procedure enabling traditional endoscopic and radiographic study of bypassed stomach and biliary tract. Surg Obes Relat Dis. 2008 Jan-Feb;4(1):16–25.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of General SurgeryFondazione Salus Clinica Di LorenzoAvezzanoItaly
  2. 2.Department of Biomedical Science for Health, Division of General and Emergency SurgeryUniversity of MilanMilanItaly
  3. 3.Division of General SurgeryIstituto Auxologico Italiano – IRCCSMilanItaly
  4. 4.Department of General Surgery, Istituto Clinico Humanitas San Pio XHumanitas UniversityMilanItaly
  5. 5.Department of General and Emergency Surgery, Ospedale Fatebenefratelli Sacra FamigliaUniversity of MilanErbaItaly

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